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Maine Department of Health & Human Services

Transfers For MAINECARE Members only
If not a MaineCare Member, DO NOT COMPLETE THIS FORM
Member Information
MaineCare #:  
Facility/Agency Information
Facility Name:
Type your facility name only if it is not in the drop-down list.
E-Mail:
Transferred to:

  
     

Special Notes
Submission Authorization:
Access Code:
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